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OP – Cardiac Catheterization/Electrophysiology Lab – Pediatric Diagnostics – Preprocedure [4623]

OP – Cardiac Catheterization/Electrophysiology Lab – Pediatric Diagnostics – Preprocedure [4623] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Diagnostics/Sedation


OP - Cardiac Catheterization/Electrophysiology Lab - Pediatric Diagnostics - Preprocedure
[4623]
Patient Care Orders
Vital Signs [126380]
Vital Signs [NURMON0013] ONCE For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Peds Diagnostic
Patient Monitoring [126463]
Measure Height [NURMON0052] ONCE For 1 Occurrences, Routine, Peds Diagnostic
Measure Weight [NURMON0015] ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
Peds Diagnostic
Nutrition [126464]
Diet - NPO [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
STRICT NPO
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail):
Tube Feeding Management:
Room Service Class:
Peds Diagnostic
Diet - NPO Except Medications [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25): NPO
EXCEPT MEDICATIONS
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail):
Tube Feeding Management:
Room Service Class:
Peds Diagnostic
Contingency Parameters for Patients Less than 7 Months of age [126469]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): ***
If systolic blood pressure < (mmHg): ***
If diastolic blood pressure > (mmHg): ***
If diastolic blood pressure < (mmHg):
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): ***
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): ***
If blood glucose < (mg/dL): ***
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): *** mL/hour
Other: Central venous pressure less than *** mmHg,Sudden
decrease in urine output
Peds Diagnostic
Contingency Parameters for Patients 7 Months to 3 Years of Age [126470]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): ***
If systolic blood pressure < (mmHg): ***
If diastolic blood pressure > (mmHg): ***
If diastolic blood pressure < (mmHg): ***
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): ***
If heart rate < (bpm):
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): ***
If blood glucose < (mg/dL): ***
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): *** mL/hour
Other: Central venous pressure less than *** mmHg,Sudden
decrease in urine output
Peds Diagnostic
Contingency Parameters for Patients 3 to 7 Years of age [126471]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): ***
If systolic blood pressure < (mmHg): ***
If diastolic blood pressure > (mmHg): ***
If diastolic blood pressure < (mmHg):
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): ***
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): ***
If blood glucose < (mg/dL): ***
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): *** mL/hour
Other: Central venous pressure less than *** mmHg,Sudden
decrease in urine output
Peds Diagnostic
Contingency Parameters for Patients 7 to 11 Years of Age [126472]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): ***
If systolic blood pressure < (mmHg): ***
If diastolic blood pressure > (mmHg): ***
If diastolic blood pressure < (mmHg): ***
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): ***
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): ***
If blood glucose < (mg/dL): ***
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): *** mL/hour
Other: Central venous pressure less than *** mmHg,Sudden
decrease in urine output
Peds Diagnostic
Contingency Parameters for Patients 11 Years of Age and Older [126473]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): ***
If systolic blood pressure < (mmHg): ***
If diastolic blood pressure > (mmHg): ***
If diastolic blood pressure < (mmHg): ***
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): ***
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

If heart rate < (bpm): ***
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): ***
If blood glucose < (mg/dL): ***
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): *** mL/hour
Other: Central venous pressure less than *** mmHg,Sudden
decrease in urine output
Peds Diagnostic
Intravenous Therapy
Intravenous Therapy [126466]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Peds Diagnostic
Premedications for Needle Insertion [126859]
Lidocaine [152737]
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, prior to needle sticks to
reduce pain. See "LMX Use Instructions" order in Active
Orders report or the Admin Instructions for application
details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply to area
greater than 100 square centimeters. (maximum 1 g/site;
maximum 1 site per hour, 6 times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to area greater
than 100 square centimeters. (maximum 1 g/site;
maximum 2 sites per hour, 6 times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do NOT apply
to area greater than 200 square centimeters. (maximum
2.5 g/site; maximum 4 sites per hour, 6 times per day).
For patients less than 1 year old do NOT leave on longer
than 1 hour. For patients 1 year or older do NOT leave on
longer than 2 hours
Peds Diagnostic
LMX Use Instructions for Premedication Prior to Needle
Insertion [NURCOM0095]
Peds Diagnostic
IV Fluids (Single Response) [126399]
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS, Peds Diagnostic
dextrose 5%-NaCl 0.2% infusion [51615] Intravenous, CONTINUOUS, Peds Diagnostic
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS, Peds Diagnostic
lactated ringers infusion [38890] Intravenous, CONTINUOUS, Peds Diagnostic
Surgical Prophylaxis
First Line (Single Response) [144087]
cefazolin (ANCEF) intraVENOUS [800000] 30 mg/kg, Intravenous, ONCE For 1 Doses, Peds Diagnostic
cefuroxime (ZINACEF) intraVENOUS [800030] 50 mg/kg, Intravenous, ONCE For 1 Doses, Peds Diagnostic
Patients with MRSA (Single Response) [144091]
Cefazolin - Vancomycin (Maximum Dose 2 grams)
[142821]
cefazolin (ANCEF) intraVENOUS [800000] 30 mg/kg, Intravenous, ONCE For 1 Doses, Peds
Diagnostic
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, ONCE For 1 Doses, Pre-Op Day Of
Procedure
Cefuroxime - Vancomycin (Maximum Dose 2 grams)
[142817]
cefuroxime (ZINACEF) intraVENOUS [800030] 50 mg/kg, Intravenous, ONCE For 1 Doses, Peds
Diagnostic
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, ONCE For 1 Doses, Peds
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Diagnostic
Patients with Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies and MRSA positive (Single
Response) [144089]
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, ONCE For 1 Doses, Peds Diagnostic
Patients with Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies and MRSA negative (Single
Response) [144090]
clindamycin (CLEOCIN) intraVENOUS [800033] 10 mg/kg, Intravenous, ONCE For 1 Doses, Peds Diagnostic
Medications
Analgesics (Single Response) [126873]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 10-15 mg/kg/dose
(Maximum 650 mg/dose) [800005]
Oral, EVERY 4 HOURS PRN, pain/fever
NOTE: Suggested dose 10-15 mg/kg/dose (Maximum 650
mg/dose)
Peds Diagnostic
acetaMINOPHEN (TYLENOL) suppository - NOTE:
Suggested dose 10-15 mg/kg/dose (Maximum 650
mg/dose) [43994]
Rectal, EVERY 4 HOURS PRN, pain
NOTE: Suggested dose 10-15 mg/kg (Maximum 650
mg/dose)
Peds Diagnostic
acetaMINOPHEN 325 mg (TYLENOL) tab RANGE
[750000]
325-650 mg, Oral, EVERY 4 HOURS PRN, pain, Peds
Diagnostic
Sedation (Single Response) [126401]
midazolam (VERSED) syrup - Maximum dose = 10 mg
[60487]
0.25-0.5 mg/kg, Oral, ONCE PRN For 1 Doses, anxiety, Peds
Diagnostic
midazolam (VERSED) 5 MG/ML intraNASAL soln
[785196]
0.3 mg/kg, Nasal, PRN For 1 Doses, anxiety, Peds Diagnostic
diazepam (VALIUM) soln - Maximum Dose = 10 mg
[36676]
0.2 mg/kg, Oral, ONCE PRN For 1 Doses, anxiety, Peds
Diagnostic
diazepam (VALIUM) soln [36676] 1 mg, Oral, ONCE PRN For 1 Doses, anxiety, Peds
Diagnostic
diazepam (VALIUM) soln [36676] 2 mg, Oral, ONCE PRN For 1 Doses, anxiety, Peds
Diagnostic
diazepam (VALIUM) soln [36676] 10 mg, Oral, ONCE PRN For 1 Doses, anxiety, Peds
Diagnostic
Laboratory
Laboratory [126477]
ALBUMIN [ALB] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ALKALINE PHOSPHATASE [ALKP] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ALT/SGPT [ALT] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
AST/SGOT [AST] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CARBON DIOXIDE [CO2] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
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If Conditional, What Condition?
Peds Diagnostic
BILIRUBIN, TOTAL [TBIL] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
B-TYPE NATRIURETIC PEPTIDE [XBNP] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CBC WITH DIFFERENTIAL [CBC] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CHLORIDE [CL] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
GLUCOSE [GLU] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
BUN [BUN] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CREATININE [CRET] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CALCIUM [CA] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ELECTROLYTES [LYTE] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HCG, QUALITATIVE, URINE [UPREG] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
LIPID PANEL [LIPID] STAT - RN COLLECT For 1 Occurrences, Routine, Test
includes Cholesterol, Total; HDL Cholesterol; Triglyceride;
LDL cholesterol, calculated; and non-HDL cholesterol.
Patient must fast for 12-14 hours and be heparin free for 48
hours prior to specimen collection. The patient can only have
water or black coffee during the fasting period.
If add on test, what should lab do if unable to add test to
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

previous specimen?
If Conditional, What Condition?
Peds Diagnostic
PLATELET COUNT [PLT] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
POTASSIUM [K] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
PROTEIN, TOTAL [TP] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
SODIUM [NA] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Diagnostic Testing and Imaging
Studies [194910]
Transesophageal Echocardiogram (PEDS) [ECH0020] ONCE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam?
Relevant recent/past history?
To whom can we send the results of the study? (include
clinician and location):
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
For during peds Cardiac Cath/EP lab procedure., Peds
Diagnostic
Transthoracic Resting Echocardiogram (PEDS)
[ECH0012]
ONCE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam?
Relevant recent/past history?
To whom can we send the results of the study? (include
clinician and location):
Do you want Agitated Bubble Study?
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
For during peds Cardiac Cath/EP lab procedure., Peds
Diagnostic
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison